Because Rowe enforces a “10-minute rule,” meaning she does not see patients who arrive more than 10 minutes after their appointment slot, she refused to see Ellie-May, an inquest heard.

Ellie-May and her mother returned to their home in Malpas, Newport, where she went to bed at about 8 p.m.

Clark said she heard her daughter coughing at about 10:30 p.m. and called an ambulance after finding her struggling to breathe, with her hands and face blue.

Ellie-May died shortly after arriving at Royal Gwent Hospital.

The inquest heard Rowe had previously received a letter from a consultant stating that the little girl was at risk of having “an episode of severe/life threatening asthma.”

According to the inquest, Rowe did not ask about the reason for Ellie-May’s emergency appointment, nor did she look into the child’s medical notes before refusing to see her.

Rob Sowersby, the lawyer representing Ellie-May’s family, told the inquest: “Dr. Rowe made a clinical decision without any clinical information whatsoever. She sent away a 5-year-old patient from an emergency appointment without even opening her records. Dr. Rowe agreed that when she opened the letter from the hospital, stating that Ellie-May was at risk of serious/life threatening asthma, she should have recorded that prominently on Ellie-May’s clinical record.”

Clark told the inquest that Ellie-May began suffering with a wheezy chest and was first admitted to the hospital in November 2011, two months before her second birthday.

She was prescribed inhalers but had returned to the hospital every three to four months, according to Clark, and was last admitted in March 2014, before her death.

In May, a consultant wrote to the Grange Clinic: “Ellie-May has previously had severe exacerbations of asthma requiring admission to the high dependency unit. This places her at risk of having another episode of severe/life threatening asthma.”

The inquest heard Rowe could have asked another doctor to see Ellie-May, could have seen her after her patient had left, and could have spoken to the doctor who arranged the emergency appointment for her.

When asked why she had not, Rowe replied: “I don’t know. I was busy seeing to the other patient that I had with me.,” adding that she would have acted differently had she read the notes regarding Ellie-May’s condition.

When asked to explain the so-called 10-minute rule, Rowe said: “If you have 25 patients to see in a morning or afternoon and a lot of people are 15 minutes late or 20 minutes late, you are never going to be able to manage your work.”

A postmortem examination by Andrew Bamber, MD, determined that Ellie-May had died from bronchial asthma and potentially suffered a seizure before her death due to a lack of oxygen.